U.S. National Library of Medicine

Transcript

As promised now, back to where you can get reliable health information. One reasonable place to start might be the world's biggest single source, the US National Library of Medicine in Bethesda, Maryland. Its Director is Dr Donald Lindberg.

Donald Lindberg: Well this is one of three National Libraries; in our case, the Library of Congress, we in the National Agricultural Library. But it is the biggest Medical Library in the world by quite a bit. Not probably the oldest, but it was founded in 1853 and supported pretty regularly since then. Our mission, we say modestly, is to acquire, organise and disseminate the bio-medical knowledge of the world for the benefit of the public health.

Norman Swan: What do you do with the rest of the day?

Donald Lindberg: Well we actually do a pretty good job of that. But in latter days we've been thinking more about how to make all this information as acquired, readily available to people, and of course take advantage of the personal computers and now the Internet and World Wide Web and all that new technology.

Norman Swan: Of course people listening who might be in the medical area vaguely, would know of the National Library of medicine through Medline. This is quite an old now, search mechanism for finding articles on a given subject that have been published in peer review journals.

Donald Lindberg: Yes, that's right. The Index Medicus actually was started in 1879.

Norman Swan: Just tell people what the Index Medicus is.

Donald Lindberg: The Index Medicus is an index of the biomedical literature of the world, so it essentially is a citation, as we call it: the name of the article, the author, the book, the journal, pages, date and that sort of thing, a bibliographical citation, and now includes of course abstracts. That was started by John Shaw Billings, as I said, in 1879. Probably really in the view of Osler when he retired, the greatest contribution of America to medicine of its day. And it has been continued steadily ever since then. It became computerised (if you don't mind that verb) in 1964, and then it became available on-line, what we call Medline, in about 1970.

Norman Swan: So long before the Internet, people were able to interrogate Medline, although in those early days, if I remember rightly, you almost had to have a degree in electronic librarianship to be able to use it.

Donald Lindberg: That's exactly right. People actually took a six-week course in how to do searching in that system. I don't see how they ever put up with it.

Norman Swan: And you've just recently made Medline free; because again, another feature of it was certainly in the early days, it was reasonably expensive to do a search and you had to be quite economical about how you went about it.

Donald Lindberg: Well the National Library of Medicine has always tried to make its direct services as cheap as possible, so we held the price down. But we have just made it free; actually the Vice President, Al Gore, did the first free Medline search. He got all the right answers, too. We did this in part because we are about to kind of turn the corner and direct our attention beyond doctors and scientists, to serve patients, families and the public a little better.

Norman Swan: So allowing them to do searches of the scientific literature?

Donald Lindberg: Yes, the effect of making it free is to multiply by ten the number of searches we do. We were doing about 7-million searches a year, we're now doing 70-million.

Norman Swan: 70-million?

Donald Lindberg: Yes.

Norman Swan: And that could be from all over the world, not just the United States?

Donald Lindberg: It is from all over the world, yes. If you know you've got a disease, or a member of your family, we give you the right article in the Medline search. We find that these patients will, maybe have to read it two or three times, maybe have to ask a friend, maybe have to use a dictionary, maybe very well prepared to discuss it next with a doctor, but get a tremendous amount of information out of it.

Norman Swan: How do you access Medline if you're sitting at your Internet computer in Dubbo, New South Wales?

Donald Lindberg: The relevant address is www.nlm.nih.gov, so nih stands for National Institute of Health, and gov is government. And that will get you to us very swiftly.

Norman Swan: But Donald Lindberg hasn't just been sitting in his office at the National Library of Medicine. Over the last decade or so, he's been one of the key players who's developed the Internet as we know it. Dr Lindberg has worked with Congress and the White House on improving the capacity of computers to talk to each other.

Donald Lindberg: We ended up with a program in the US called High Performance Computing and Communications. Essentially it was a program joint between ten and then ultimately 14 US Federal agencies. To make a long story short, we set a five-year goal to produce computers that would operate a thousand times faster than they could at the time, and connected by transmission lines. That was a five-year goal that was achieved in 2-and-a-half-years.

We changed the definition of the project to a metaphor of electronic highway of the future, the goal became to serve everybody in the US, later actually enlarged to a global network with the Internet that we now see with many, many millions of users in virtually all countries of the world, a connectivity that was undreamed of ten years ago.

It is of course, getting clogged, as you might expect.

Norman Swan: Which is partly because the transmission lines that we were discussing earlier only exist for a relatively few people; most people are still going down copper wire.

Donald Lindberg: Yes, it's the transmitivity which is the problem. So in fact we have a new program now called NGI, Next Generation Internet. It's a bit of a mystery exactly where these blockages are occurring. Chums of mine in London, when they would see me they would say, 'Well you know, Internet's fine until you Americans wake up.' So we did some tests to see how long it does take large and small packages to arrive, and where the delays are and so forth. And it turns out that actually Internet gets clogged in London when Britain wakes up. Now when both of us are awake, it's really ghastly, but most of the obstruction is local, and I'm sure that we've shown that that's the same case in the other - well in Sweden, and in our major cities in the US.

The bottom line is that most of these obstructions are within a hundred yards of your desk. I mean they're routers, usually, they're devices in closets, they're not lines under the ocean.

Norman Swan: But back to this link between health and all this connectivity, because it's allowed the National Library of Medicine to create what they call 'knowledge representation.' One of the first examples of this was the Visible Human Project. Donald Lindberg again.

Donald Lindberg: The Visible Human is a three-dimensional representation of the entire sub-millimetre anatomy of an adult male and an adult female cadaver. So it's the classic, the anatomy of the human. Done as an NLM experiment, it's on the Internet, available throughout the world. That's a new form of representation, that's anatomy tied to the texts that describe it.

Norman Swan: This was a criminal or something like that in the Southern States who was carved up?

Donald Lindberg: Well, you say it that way.

Norman Swan: Well, IÆm a journalist, what do you expect?

Donald Lindberg: Yes, well, first of all there were a number of candidates, both male and female, to do this. And my requirement was that each one of them have willed their body to science while they're alive. It happened that we selected a convicted criminal in the case of the male; and in the case of the female it was a lady who read about the first case, made a decision with her husband that if either of them died, they would like to be in that project, so she was a very, very fully informed decision.

Norman Swan: Another area which has been talked up considerably with the development of all these connected computers, is treating and diagnosing medical problems at a distance, so-called telemedicine.

It's a bit of a fallacy to think that this is new, since the person who invented the electrocardiogram at the turn of the century, tried to send ECGs down the telephone line. And the Flying Doctor Service has been treating people by radio and telephone for decades.

But nowadays the enthusiasm for computer linked telemedicine knows no bounds.

Donald Lindberg: I might say that it's one of the projects of the G7 countries; Australia is not a formal member of G7, but there's an Australian observer at every single one of these, and they're very, very keen on, I think appropriately, on telemedicine. You all have some even more big open spaces than we do. Every week I hear about a new interesting telemedicine application that I wouldn't have thought of myself.

Norman Swan: What was the one last week?

Donald Lindberg: Well the one last week that caught my eye was home health care, where the computers are used so that let's say, a visiting nurse, can make a call to six or eight patients let's say in the morning, by staying at home and using a closed circuit, well using a computer on a television cable, where she would only have been able to visit one or two possibly, were she driving about.

The early results show that these are patients who are quite competent to live alone. They may be elderly, they may have some disease, maybe diabetes or whatever; they very much benefit from these electronic visits.

Norman Swan: But is there a limit? One can understand if you're a remote doctor in a country town and there's no radiologist in town and you've just done an X-ray on the hospital X-ray machine and you're not quite sure what you've just seen. To be able to send it down with this new high capacity and get it down reasonably cheaply to a major teaching hospital for an expert radiologist to have a look at it, is marvellous. However for a clinical consultation at a distance, there is some evidence that people actually do prefer the contact with the doctor. Where are the limits?

Donald Lindberg: Well if you ask me, I would vastly prefer to go to the best doctor I know and sit down and have a long talk with him, but I may or may not be able to do that. How fast a line is required to give a satisfactory consultation, this is part of the research that we're carrying out. We first of all want to show is there a medical benefit, and secondly, what does it cost, and if money is spent or saved, whose is it.

The research projects in Telemedicine we support include some that use very low technology, if you will. One of them is a teledermatology project, so diseases of the skin, which just uses simple digital cameras, ordinary telephone lines; it's run by the Oregon Health Sciences University on our west coast, where there are pretty big distances and pretty remote areas. They are seeing incredibly good success with this system. Of course it uses a personal computer, but that's not very expensive nowadays. And what they're saying is patients who have perhaps seen two or three or four doctors, have had diseases as much as seven or eight years, which to be frank are easy for the expert dermatologist to diagnose, just looking at the picture on a computer screen and do elude the diagnosis of many of us who are not experts.

Norman Swan: Despite everybody getting on the bandwagon of the Internet, and figures which some people would dispute about how many people are actually connected to the net, you can to and fro on that, there are still a lot of people who are not connected, who can't afford it, or find the technology daunting, who still need the information and in fact in many situations they're the very people who do need the information and don't lack the wit to understand it. What solutions are there for them, when people like yourself are focusing on the electronic world to provide it?

Donald Lindberg: Well I'm going to continue focusing on the electronic world. I mean there was a time when not everybody had a telephone service.

Norman Swan: However, you still come to the equipment that you're attached to the end of it, and the ability to afford that.

Donald Lindberg: Absolutely. I don't think the problem is providing a machine that can talk to the data lines, I think where there are problems throughout the world, the problems are not poverty at that level, the problems are political stability and instability. I mean we see this many, many times. Every time we establish a -- we have 25 overseas centres and are building more collaborations, partnerships, and where the troubles arise they're political instability, they're not lack of dollars or other currency.

Norman Swan: Dr Donald Lindberg, who's Director of the US National Library of Medicine. Their website is www.nlm.nih.gov.